Outpatient CT Form

Countryside Veterinary Medical Group offers outpatient CT services for your patient's diagnostic needs. A CT scan will be performed on the requested region of the pet under general anesthesia. The scan will then be reviewed by our consulting radiologist with a diagnosis and a direction for your treatment plan. All pets will be referred back to your general practice for further care.

Read and complete the following prior to sending the form:

Owners should anticipate that their pet may need to stay at Countryside Veterinary Medical Group for the day.

Patients need to have fasted 12 hours prior to the appointment. You will be sent the CT results within 24 hours. If you decide you would like to have a consult with one of our specialists, please let us know and we will accommodate any additional needs.

Contact CVMG to review the case and ensure that the case qualifies for an outpatient CT.
Upload (or send via email or fax) available medical records and diagnostics to CVMG (Lab work that has been done within 30 days of the CT scan can be used as pre-anesthetic bloodwork).
If we do not receive this Outpatient CT Referral Form prior to the scheduled appointment, we will be unable to perform a CT scan.

Download a PDF Version

Referring Veterinarian Information

Veterinarian*

Veterinary Hospital*

Hospital Phone*

Hospital Fax

Hospital Email

Doctor's Email

Client/Patient Information

Client First/Last Name*

Phone*

Client Email

Pet Name*

Date of Birth*

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Species*

Cat

Dog

Breed

Color

Indication for CT Scan*

Region of Body to Scan*

Known Concurrent Conditions*

Current Medications and Doses*

Known Allergies*

Please note that if your patient needs further diagnostics and/or treatment before anesthesia/CT is performed OR the CVMG doctor in charge has concerns performing anesthesia and/or if your patient is deemed medically unstable upon arrival to CVMG, the attending doctor will contact you to discuss concerns and make recommendations necessary to stabilize the patient prior to anesthesia and CT scan.

Please email available medical records and diagnostics to countrysidevets@yourvetdoc.com.

Initial*